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„���. ��t� '�kF`r. -ez�:` v 4�r•�t":.. �t �� s�•xry. �:�Si:ax ; '�.•.�:'ar ��� t� � �•�{`rTai �g'yt� .y,� � ,.,�; V .a yr ..�:z <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> yU.4, APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAy <br /> ,AdZ:.I!r/ Norn <br /> orl <br /> A;;dfai 60184 <br /> L*cor;on of Proposed Wwic,et APPROVED: DIRECTOR OF PUBLIC WORKS <br /> el <br /> Owrw/Cantroctor Ad&fts <br /> B _Dat <br /> Estimated Starting Dore.-�;6 COMPI e2 <br /> Wian DOR Permit Expiration Dare <br /> I for Well hereby apply for an encroachment permit to carry out the following <br /> X <br /> T <br /> he above named applicant hereby requests permission io PERMIT FEE <br /> $ S3 SG <br /> Additionot Footoio-I". <br /> Sewer Top Deposit..................... <br /> TOTAL DEPOSIT ........... S <br /> S <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> Show sketch above or refer to drowing submitted <br /> IMPORTANTr Applicant hereby agrees to comply with all provisions of this permit as well 03 all applicable City ordinances, <br /> resolutions, dandords and specifications currently in effect, and <br /> ment of any item which doe-; not meet above requirements. Failure <br /> Pay to City its actual cost for removal and proper replac <br /> ilure to comply will be cause for revocation of permit, Appe' <br /> 11' <br /> cont agrees to indemnify and hold the City harmless against any and all losses, costs, or damages 10-Whing ffr;)-: injury to <br /> persons, death of person or damage to properly occurring at the site of or as 0 result Of work to be performee under this <br /> permit. Certificate of insurance will be 'presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit before signing, 'Note requirement of notifications and Inspections. <br /> Permit Eng Ineerl Inspector <br /> 944,&W <br /> 944.8366 <br /> Signed: L <br /> —Phone /—QR- <br /> 7 208 <br /> _Ptr_IIte* 2nd Fac <br />